Medicaid Health Plan Pharmacy Benefit
Update - Proposed Pharmacy Carve-Out Policy
This is an update to Proposed Pharmacy Carve-Out Policy (1936-Pharmacy) issued on September 30, 2019: Medicaid Health Plan Pharmacy Drug Coverage Transition. This policy proposed that Managed Medicaid outpatient pharmacy drug coverage would fully transition to Fee-for-Service (FFS) Medicaid. After careful consideration, the proposed pharmacy transition is not moving forward. As recommended in the Governor’s Executive Budget, the Department will instead be implementing a single Medicaid Preferred Drug List (PDL). The single PDL will maximize drug manufacturer rebates to generate additional budgetary savings. In an effort to ensure the financial sustainability of Michigan’s independent pharmacies, the Department has also proposed raising the Medicaid Health Plan dispensing fee for independent pharmacies to $3.
The Department is preparing a proposed policy for the Single PDL which, in accordance with existing procedure, will include an opportunity for public comment.
As a reminder, Fee-For-Service Medicaid pharmacy coverage questions can be directed to MDHHSPharmacyServices@michigan.gov. Medicaid Health Plan Common Formulary pharmacy coverage questions can be directed to MDHHSCommonFormulary@michigan.gov.
This webpage is designed to provide easy access for members and providers looking for information on the drugs and supplies covered by Michigan Medicaid Health Plans.
All plans must at a minimum cover the drugs listed on the Medicaid Health Plan Common Formulary.
|FOR PROVIDERS AND PRESCRIBERS ONLY|
|Prior Authorization (PA)||Step Therapy|
The Prior Authorization criteria for drugs indicated on the Medicaid Health Plan Common Formulary as requiring PA is below:
A standard prior authorization form, FIS 2288, was created by the Michigan Department of Insurance and Financial Services (DIFS) to simplify the process of requesting prior authorization for prescription drugs. This form or a prior authorization used by a health plan may be used.
The Step Therapy criteria for drugs indicated on the Medicaid Health Plan Common Formulary as requiring ST is below:
Scroll down for health plan specific information.
MEDICAID HEALTH PLANS
Plans may choose to include additional drugs that are not on the Medicaid Health Plan Common Formulary in their own drug formularies. In addition, plans may enforce drug utilization management policies such as quantity limits, age and gender edits, prior authorization criteria and step therapies that are less restrictive than the coverage parameters of the Medicaid Health Plan Common Formulary. Click on the health plans below for more information about their formularies and pharmacy related contact information.
Current beneficiaries can find out which health plan they are enrolled in by calling the Beneficiairy Help Line at 800-642-3195 (TTY 866-501-5656) or by logging in to their myHealth Portal account online at www.michigan.gov/myhealthportal.
For more information on the drug benefit for people not enrolled in a health plan (Fee-for-Service Medicaid) visit https://michigan.magellanrx.com .
For more general information on Michigan Medicaid Health Plans, visit www.michigan.gov/managedcare.
STAKEHOLDER MEETINGS AND COMMENT PERIOD
Public Comment on MDHHS Medicaid Health Plan Common Formulary:
The Michigan Department of Health and Human Services (MDHHS) is soliciting comments from the public on the Michigan Medicaid Health Plan Common Formulary. The Common Formulary applies to pharmacy claims paid by Medicaid Managed Care Organizations – it will not apply to claims paid through Fee-for-Service. The public may submit comments on the drugs included or not included on the Common Formulary, new drug products, prior authorization criteria, step therapy criteria and other topics related to drug coverage under the Common Formulary. The comments will be reviewed by MDHHS and the Michigan Medicaid Health Plan Common Formulary Workgroup. The next drug classes to be reviewed by the Workgroup include Diabetes, GI, P & T Miscellaneous, Non-Drug Products and Endocrine & Metabolic. Changes may be made to the Common Formulary based on comments received. Comments will be solicited once per calendar quarter.
Please send your comments by August 14, 2020 to:
Linda VanCamp, Formulary Analyst
Bureau of Medicaid Care Management & Customer Service
Medical Services Administration
P.O. Box 30479
Lansing, Michigan 48909-7979
Telephone Number: 517-245-2758
Fax Number: 517-763-0142
E-mail Address: MDHHSCommonFormulary@michigan.gov